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SR0026562
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HAMMER
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2900 - Site Mitigation Program
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SR0026562
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Entry Properties
Last modified
9/20/2022 8:16:50 AM
Creation date
9/20/2022 7:55:49 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
SR0026562
PE
3501
FACILITY_NAME
QUICK STOP MARKET NO.132
STREET_NUMBER
3333
Direction
W
STREET_NAME
HAMMER
STREET_TYPE
LN
City
RIVERBANK
Zip
95367
ENTERED_DATE
6/25/2001 12:00:00 AM
SITE_LOCATION
3333 W HAMMER LN
QC Status
Approved
Scanner
SJGOV\tsok
Tags
EHD - Public
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06/19/2000 03:30 <br />925 -463 -?559 <br />ATC PLEASANTON <br />WELL PERMIT APPLICATION FORM <br />SAN .IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA,, 95202 <br />(209) 468-3449 <br />PAGE 06 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />p PERMPERMrr EXPIRES ISQU122 <br />Application Is hereby made to San .ioKkAn County for a permit to construct an&ar install the worlt described. This application Is made in compliance with San <br />Jgaquln County Development Tltle. Chapter 9-1115.3 and the Smrdardsof an Joaquin Caunty Public Health Servioes, Environmental Health Division- <br />p,�, /J //,,yy [�,,,� Asse5sOr's <br />WELL Location / �� '+ `'Gross Stree! Wl ityip Parcel#. <br />PROPERTY Ownefl warn=.. " ��✓YO Cityr/�hone#�f,r4Y� �?9 <br />SGi��%�E�/ f� C i c4rlll_hone# -A <br />0.57 <br />0.97 Contractor Adtlress <br />ConSu1W nt /Sub Contractor T L.1 ®�• Address P Phuns#-�d���r/ -� <br />GIS Coordinate X YTownship - /SC Rang5e-tion <br />WORK TO BE PgRFORM9Q& <br />(j NEW WELL I BORING ( CPT > OPROBE, HYD P �j H D -AUGER, OTHER-) a DESTRUCTION (choose type below) <br />SOIL BORING #'/� ' Q OVER -BORE <br />WELL tf p PRESSURE GROUT �i�1 <br />'Other: Grout Spedflcttlons: "A <br />COMMENTS: e <br />7YpE OFA" IN21ALLATION ME <br />Q MONITORING 13 HOLLOW STEM <br />p EXTRACTION a AIR HAMMER/DRIVEN <br />!] VAPOR a MUD ROTARY <br />Q AIR SPARGE 0 PUSH POINT <br />[.SOIL BORING U HAND AUGER <br />p OTHER:_ - -- - �[] OTHER <br />(�NgTR17CT10N SPECIFiCATIC�I.$ <br />DIA. OF BOREHOLE MULTIPLE CASINGS? [I YES ONO WELL CASING Dill <br />CASING THICKNESS TYPE OF CASING, 0 STEEL 0 PVC J]OTHER; <br />OEPTH OF GROUT SE 'PREMIE TYPE TO BE USEO- fl AUGERS 0 HOSE <br />GROUT SEAL PUMPED; p Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS. <br />APPROX. BORING DEPTH _ -„ p BOLTED TRAFFIC BOX or 11 STOVE: PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list spedfiratlons here): <br />-COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 49 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules 250 Regulations, and all applicable California State Laws. ��'5/_9 <br />� pper�..,, <br />Signed x <br />,P�,�J TiUalCompany C :F� ��' <br />Print Name �i <br />n9PARTMENT USE QNLY <br />SITE MAP IN UNIT 1V FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By ..� Is9ued ey� <br />Grout Inspection 3y _ 08t® Final Inspection By Date <br />Destruction Insoectlon By Date <br />COMMENTS / CONOrrIONS: <br />ACCOUNTING ONLY: I AiL30 <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS REG'D BY I DATC PERMIT! SE1 <br />WG �WAiEP <br />V,_ C-57 Letter of Authorization to sign permit Encront <br />UINVOICE <br />EST ik <br />oc - 9/27/00 <br />
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